Authorizations

Family Care Members

• Authorization is required prior to rendering ALL services for Family Care
• Contact the member’s care team to get an authorization
• The member’s care team will enter the authorization. Providers will be able to see and/or print the authorization from the MIDAS portal.
• If you cannot reach the member’s care team, contact our Customer Service team at 1-800-963-0035

Partnership, and Medicare Dual Advantage Members

• Use the My Choice Wisconsin form appropriate for the service and fax to (608) 210-4050. Forms can be found in the library below or in the Provider Resource Library. 
• For Dental Prior Authorizations contact Skygen:
  • Phone: (800)508-4890
  • Website: https://pwp.skygenusasystems.com/PWP/Landing
• For Vision Prior Authorizations contact VSP: 
  • Phone: (855)492-9028
  • Website: https://www.vspproviderhub.com/contact.html

Prior authorization is required for all:

• Non-emergent hospital admissions
• Skilled Nursing Facility (SNF) stays
• Sub-acute psychiatric community-based crisis stabilization stays
• Long Term Acute Care (LTAC) stays

For urgent or emergent hospital admissions:

• Notify My Choice Wisconsin within one (1) business day
• Use the My Choice Wisconsin form appropriate for the service and fax to (608) 210-4050. Forms can be found in the library below or in the Provider Resource Library. 

Our process:

• Initial Review – Once we have been notified of the admission, the member’s case will be assigned to a Utilization Review RN who will process for medical necessity using InterQual and other evidenced-based clinical standards of care.
• Care Management – The My Choice Wisconsin Care Team staff is also notified of the admission and is available to discuss the member’s discharge needs.
• Certification – We will issue written certification of all stays that meet medical necessity within one business day of receiving pertinent clinical documentation.
• Concurrent Review – My Choice WI performs concurrent review to ensure medical necessity and appropriateness of continued care and only reimburses for services that are medically necessary based on the information provided by our contracted providers. All continued stay clinical is to be faxed to 608-210-4050 on the last “approved dates of service” for timely medical review.
• Ongoing Communication – My Choice Wisconsin will continue to issue certification letters for additional days meeting medical necessity.
• Secondary Review – If at any time a stay is not meeting medical necessity or the appropriate level of care is not met, it will be reviewed by a My Choice Wisconsin Medical Director.
• Peer to Peer: Molina Healthcare has a full-time Medical Director available to discuss medical necessity decisions for Inpatient Hospitalizations with the requesting physician. Please contact our Customer Service center at (800) 963-0035 to set up a time to discuss the case.  Peer to Peer reviews must be requested within 5 business days from the date of discharge or date of denial, whichever is later. For Skilled Nursing Facilities, Acute Inpatient Rehabilitation stays, and Long-Term Acute Care Hospitalizations a peer to peer will not change the initial admission decision. “To change a determination from unfavorable (denial) to favorable (approval), an appeal must be filed. A physician discussion (peer-to-peer) is encouraged to understand the reason for the denial and to coordinate care. However, no change to the organization’s determination can be made as a result of the physician discussion.”
• Notification of Decision: My Choice Wisconsin will notify the servicing provider within one business day of making a decision to deny a stay deemed not medically necessary. The member, requesting provider, and servicing provider will also be issued written notification within 24 hours of making the decision to deny as not medically necessary.

Family Care Members

All services rendered through the Family Care program require prior authorization through the care team. Retroactive authorization requests are not permitted for this program and will not be approved. 

Partnership, and Medicare Dual Advantage Members

All authorization requests are subject to member eligibility, benefit plan coverage, and medical necessity.

A retroactive authorization will be accepted if it meets the following requirements:

• Request is received by My Choice Wisconsin within 14 calendar days of the start of the provision of services
• Request precedes a bill for services
• Request includes justification for beginning the service prior to receiving authorization:
  • The member was not able to tell the provider about their insurance coverage prior to rendering services, or
  • The provider verified different insurance coverage prior to rendering services

Family Care

• All services rendered through the Family Care program require prior authorization through the care team.

Partnership

• Prior authorization is not required for outpatient services for secondary coverage when Medicare or other commercial insurance is providing primary coverage, consistent with DHS 107.02.
• If Medicare or other primary insurance does not cover a service and you are seeking primary coverage from My Choice Wisconsin, all prior authorization requirements apply.

• My Choice Wisconsin administers Wisconsin Medicaid healthcare benefits through our Family Care, and Partnership programs and complies with Wisconsin Administrative code outlined in DHS 107.03. 
• The Family Care and Partnership programs include Home and Community-based Waiver benefits in addition to traditional Medicaid coverage.
• My Choice Wisconsin provides Medicare benefits to members in our Dual Advantage program, as well as dual-eligible members in our Partnership program. My Choice Wisconsin administers the benefits consistent with original Medicare. Please see Items and Services Not Covered Under Medicare for more information.